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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004795
Report Date: 05/02/2022
Date Signed: 05/02/2022 11:09:51 AM

Document Has Been Signed on 05/02/2022 11:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:WESTMINSTER VILLAFACILITY NUMBER:
306004795
ADMINISTRATOR:PATTY OSUNAFACILITY TYPE:
740
ADDRESS:13881 DAWSON STREETTELEPHONE:
(714) 534-7880
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 200CENSUS: 133DATE:
05/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Ana Kunz and Patty OsunaTIME COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit in conjunction with complaint visit 22-AS-20220422163644. LPA was greeted and granted entry into the facility by CEO Ana Kunz explained the reason for the visit. Administrator Patty Osuna was present as well.


During the course of the complaint investigation, LPA was advised the second elevator in facility is inoperable. Facility staff confirm the elevator is inoperable. LPA observed the main elevator is operational. LPA toured R1's room during the visit and observed the resident's rest room does not have an emergency pull cord in the restroom.



Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with CEO Kunz and a copy of the report was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2022 11:09 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 05/02/2022 at 10:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WESTMINSTER VILLA
FACILITY NUMBER: 306004795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2022
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met as evidenced by:
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licensee to repair/ replace elevator as well as install emergency pull cord in resident's room. Licensee to forward proof to LPA by POC due date.
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Based on interview and observation, Licensee failed to ensure facility is safe and in good repair. Elevator in facility is inoperable and R1's room does not have an emergency pull cord. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022


LIC809 (FAS) - (06/04)
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